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Published on: January 18, 2018
Revascularisation strategies for non-acute myocardial ischaemic syndromes
Michal J Kawczynski1,2, Fabio Barili3,4,5, James M Brophy6
1Department of Cardiothoracic Surgery, Maastricht University Medical Center, Maastricht, Netherlands.
Insights
Coronary artery bypass grafting (CABG) shows better long-term outcomes than percutaneous coronary intervention (PCI) for non-acute myocardial ischaemic syndromes, though stroke risk is similar. Both revascularisation strategies offer advantages over optimal medical therapy alone.
Area of Science:
- Cardiology
- Interventional Cardiology
- Evidence-Based Medicine
Background:
- Contemporary guidelines on non-acute myocardial ischaemic syndromes show discrepancies in revascularisation recommendations.
- European Society for Cardiology and American College of Cardiology/American Heart Association guidelines differ on revascularisation value.
- A need exists to compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) effectiveness.
Purpose of the Study:
- To evaluate the comparative effectiveness of CABG versus PCI against optimal medical therapy (OMT) for long-term outcomes.
- To assess the incremental effectiveness of revascularisation strategies in non-acute myocardial ischaemic syndromes.
- To provide evidence for guideline development regarding revascularisation in ischaemic heart disease.
Main Methods:
- Hierarchical Bayesian network meta-analysis of randomized controlled trials (RCTs) published between 2005 and 2025.
- Included three treatment arms: OMT, PCI+OMT, and CABG+OMT.
- Primary outcome: all-cause mortality; secondary outcomes: myocardial infarction, stroke, and re-revascularisation rates, analyzed using hazard ratios (HRs) and surface under the cumulative ranking curve (SUCRA).
Main Results:
- Analysis of 10 RCTs with 10,742 patients.
- CABG+OMT showed a trend towards lower all-cause mortality (HR 0.84) compared to OMT, while PCI+OMT did not (HR 0.93).
- CABG+OMT demonstrated high likelihoods of being optimal for mortality (SUCRA 88.1%), myocardial infarction (99.7%), and re-revascularisation (99.5%), but not stroke (17.5%).
Conclusions:
- Initial CABG+OMT strategy is associated with a higher probability of optimal outcomes compared to initial PCI+OMT, except for stroke.
- While confidence intervals overlap, suggesting some uncertainty, CABG appears more favorable for long-term mortality and repeat procedures.
- Findings suggest CABG may be preferred for comprehensive long-term benefits in selected patients with non-acute myocardial ischaemic syndromes.
Background:
Contemporary guidelines by the European Society for Cardiology and American College of Cardiology/American Heart Association for the treatment of non-acute myocardial ischaemic syndromes dispute the value of revascularisation and differ in their recommendation to perform revascularisation. A Bayesian network meta-analysis was performed, evaluating the strength of evidence for the comparative incremental effectiveness of coronary artery bypass grafting (CABG) versus percutaneous coronary intervention (PCI) over medical therapy on long-term outcomes.
Methods:
A hierarchical Bayesian network meta-analysis was designed (PROSPERO CRD42024541215, date 20 May 2024), including randomised controlled trials (RCTs) published between 2005 and 10 June 2025, which consisted of three initial treatment modalities: optimal medical therapy (OMT), PCI+OMT and CABG+OMT. The primary outcome was all-cause mortality at maximum follow-up; secondary outcomes were trates of the rates of myocardial infarction, stroke and re-revascularisation at maximum follow-up, expressed in HRs and 95% credible intervals (CrIs), accompanied by surface under the cumulative ranking curve (SUCRA) scores.
Results:
10 RCTs, comprising 10 742 patients, were included. For all-cause mortality, the estimated median HR of CABG+OMT versus OMT was 0.84 (95% CrI 0.68-1.07); the HR of PCI+OMT versus OMT was 0.93 (0.79-1.16); and the HR of CABG+OMT versus PCI+OMT was 0.91 (0.71-1.13). The SUCRAs of a CABG+OMT strategy ranking as the optimal revascularisation treatment regarding mortality, myocardial infarction, stroke and re-revascularisation were 88.1%, 99.7%, 17.5% and 99.5%, respectively. Results were consistent across sensitivity analyses, including in the node-splitting models.
Conclusions:
This Bayesian network meta-analysis found that an initial CABG (+OMT) revascularisation strategy was associated with higher probabilities of optimal outcomes, with the exception of stroke, compared with an initial PCI (+OMT) revascularisation strategy, although CrIs overlapped, suggesting that some uncertainty remains.
Prospero Registration Number:
CRD42024541215.
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